Fact Sheet. Background OVERDOSE REPORTING REQUIREMENTS

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1 OVERDOSE REPORTING REQUIREMENTS Fact Sheet Background The number of opioid-related overdose deaths in the United States continues to increase. In 2015 alone, over 52,000 Americans died of drug overdose, an average of nearly 150 every day. 1 Most of these deaths are due in whole or part to opioids, both prescription painkillers and illicit drugs like heroin. Recently, powerful synthetic versions of the drug fentanyl have begun to infiltrate the illicit drug market, driving a significant increase in overdose deaths. 2 Unfortunately, both variations among jurisdictions in determining and causes of death and delays in obtaining and fatality data often result in an incomplete and out-of-date view into this rapidly evolving epidemic. Particularly as powerful synthetic opioids increasingly populate the illicit drug supply, it is imperative that health departments and other relevant actors are provided with accurate, timely and actionable information on drug-related overdose. To help achieve this goal, five states (Arizona, Nevada, New Mexico, Rhode Island, and Texas) now require health care practitioners to report overdose cases in a timely manner to the state health department or other governmental agency. Additionally, Wisconsin requires law enforcement officials to report overdoses to the state prescription drug monitoring program (PDMP) and West Virginia requires medical professionals to do the same. Florida permits emergency medical services to report overdoses to the state health department. Further, two counties in Washington have made overdose reportable to the local health department. Legislation has been introduced in several other states that would permit or require overdoses to be reported. However, most states have not changed law or policy to require timely of non-fatal overdose. Because all states have a system by which certain diseases and conditions are required to be reported to the state health department, typically within a relatively short period of time, adding non-fatal overdose to the list of reportable conditions may be an effective and cost-effective way of improving access to this important data. In most states, legislation provides the state health department or similar agency with broad authority to modify the list of reportable diseases or conditions, often through sub-regulatory means. 3 Other mechanisms, such as EMS data collection and systems, may also be useful in providing data that may be used to identify changes in overdose frequency and type, which may permit health departments and other entities to more effectively target interventions. The tables below provide a snapshot of current and proposed laws, regulations, and sub-regulatory sources governing mandatory disease and a description of the laws and regulations governing of overdoses in the jurisdictions that require or explicitly permit it. Table 1 presents the results of a 50 state survey of required overdose by health care providers, including links to relevant law and regulation. Table 2 provides information on the jurisdictions that require or explicitly permit overdose to be reported, and Table 3 provides information on states with Updated May 15, 2017

2 pending legislation. In light of the rapidly evolving epidemic, other states may wish to modify legislation, regulation, or policy to improve timely access to actionable data on overdose, particularly non-fatal overdose. Table 1: Health Care Reporting of Overdose Jurisdiction Overdose required? Relevant Law or regulation Subregulatory source Notes 4 Alabama No ALA. ADMIN. CODE r , App. I ADPH Per regulations, outbreaks of any kind and cases of potential health importance as determined by the healthcare provider must be reported within 24 hours. Alaska No ALASKA ADMIN. CODE tit AK DHSS Regulations require immediate of an outbreak or an unusual number or clustering of diseases or other conditions of public health importance. Arizona Yes ARIZ. ADMIN. CODE AZ DHS Several overdose-related conditions are required to be reported under the authority of a gubernatorial Executive Order. See Table 2 below. Arkansas No ARK. CODE R V ADH Regulations note that Any unusual disease or outbreak must be reported immediately to the Department. California No CAL. CODE REGS. tit 17, 2500, 2806; CAL.HEALTH & SAF. CODE CA DPH Regulations require of disorders characterized by lapses of consciousness but definition doesn t seem to encompass overdose. Colorado No 6 COLO. CODE REGS CO CDPHE [A]ny unusual illness, or outbreak, or epidemic of illnesses, which may be of public concern whether or not known to be, or suspected of being, communicable is required to be reported. Connecticut No CONN. AGENCIES REGS. 19a-36-A2 CT DPH Delaware No DEL. ADMIN. CODE 3.1 DE PH Per Delaware administrative code, [C]lusters of any illness which may be of public concern must also be reported. Florida No FLA. ADMIN. CODE r. 64D FL DOH Legislation passed in 2017 permits but does not require basic and advanced life support services that treat or transport a person for a suspected or actual overdose of a controlled substance to report such incidents to the department. See Table 2 below. Georgia No GA. CODE ANN GA DPH Per DPH, any cluster of illnesses must also be reported. Page 2 Updated July 1, 2017

3 Jurisdiction Overdose required? Relevant Law or regulation Subregulatory source Notes 4 Hawaii No HAW. REV. STAT HI DOH Idaho No IDAHO ADMIN. CODE r ID DHW Per DHW, Extraordinary occurrence of illness including syndromic clusters with or without an etiologic agent, including suspected cases, must be reported within one day. Illinois No ILL. ADMIN. CODE tit. 77, IL DPH Per DPH, Any unusual case or cluster of cases that may indicate a public health hazard is required to be reported immediately and outbreaks of public health significance are required to be reported within 24 hours. Indiana No 410 IND. ADMIN. CODE ISDH Iowa No IOWA ADMIN. CODE r IA DPH Kansas No KAN. ADMIN. REGS KS DHE Per DHE, outbreaks and unusual occurrence of any disease should be reported within 4 hours. Kentucky No 902 KY. ADMIN. REGS. 2:020 KY CHS Per CHS, any outbreak, defined as two or more cases.. that are epidemiologically linked or connected by person, place, or time must be reported immediately. Louisiana No LA. ADMIN CODE. tit. 51, pt. II, 105 LA DPH Maine No ME. CODE R. 258, 2 ME DHHS Per DHHS, any cluster/outbreak of illness with potential public health significance is immediately reportable. Maryland No MD. CODE REGS MD DHMH An outbreak of a disease of known or unknown etiology that may be a danger to the public health is required to be reported, but guidance from DHMH clarifies that this requirement is intended to apply to grouping or clustering of patients having similar disease, symptoms, or syndromes that may indicate the presence of a disease outbreak. Proposed legislation includes specific overdose requirement; see Table 3 below. Massachusetts No 105 MASS. CODE REGS MA DPH Per DPH, any case of an unusual illness thought to have public health implications is also reportable. Page 3 Updated July 1, 2017

4 Jurisdiction Overdose required? Relevant Law or regulation Subregulatory source Notes 4 Michigan No MICH. COMP. LAWS MI HHS HHS also requires the of the unusual occurrence, outbreak or epidemic of any disease or condition. Minnesota No MINN. R MDH Mississippi No MISS. CODE R Appendix A MSDH Poisonings are required to be reported to the Mississippi Poison Control Center within one week. It does not appear that this requirement is being interpreted to include drug overdose. Missouri No MO. CODE REGS. tit. 19, MO DHSS Outbreaks or epidemics of any illness, disease or condition that may be of public health concern are required to be reported within one day. Montana No MONT. ADMIN. R MT DPHHS Rule requires the of any unusual incident of unexplained illness or death in a human or animal with potential human health implications, but applies only to communicable diseases. Nebraska No 173 NEB. ADMIN. CODE, ch. 1, NE DHHS Nevada Yes NEV. ADMIN. CODE 441a a725 NV DHHS Recently passed legislation requires cases and suspected cases to be reported, but regulations are not yet in place. See table 2. New Hampshire No N.H. CODE ADMIN. R. LAB. He-P NH DHHS New Jersey No N.J. ADMIN. CODE 8: NJ DH Rule provides that health care providers must report to the department any disease or condition that could reasonably lead to a public health emergency. New Mexico Yes N.M. CODE R NM DH Drug overdose is a reportable condition. See detailed information in table 2. New York No N.Y. COMP. CODES R. & REGS. tit. 10, 2.1 NY DH Rule provides for the of any unusual disease, but the definition does not appear to apply to overdoses. In New York City, poisoning by drugs or other toxic agents is a reportable condition, but this requirement does not appear to be applied to drug overdose. The State Assembly is considering S05499 which would establish opioid overdose requirements for certain practitioners. See Table 3 below. Page 4 Updated July 1, 2017

5 Jurisdiction Overdose required? Relevant Law or regulation Subregulatory source Notes 4 North Carolina No 10A N.C. ADMIN. CODE 41A.0101 NC DHHS North Dakota No N.D. ADMIN. CODE ND DH Ohio No OHIO ADMIN. CODE and OH DH Rule provides for the prompt of other contagious or infectious diseases, illnesses, health conditions, or unusual infectious agents or biological toxins posing a risk of human fatality or disability, as specified by the director of health. Oklahoma No OKLA. ADMIN. CODE 310: and 310: OK SDHP Rule allows the Commissioner of Health to designate any disease or condition as reportable for a designated period of time for the purpose of special investigation (see Okla. Admin. Code 310: ). Oregon No OR. ADMIN. R OR HA Pennsylvania No 28 PA. CODE PA DH Regulations require the of a public health emergency and the of the unusual occurrence of a disease, infection or condition not listed as reportable in the rule within 24 hours. Rhode Island Yes R.I. Code R. 4.0 RI DH Overdoses are not a reportable condition in RI, but a separate regulation requires of confirmed and suspected opioidrelated overdose cases. Additionally, by policy, the state medical examiner reports accidental overdose deaths to the Office of Vital Records at the Department of Health. See Table 2 below. South Carolina No S.C. CODE REGS and 6-21 SC DHEC SC s list of reportable conditions includes outbreaks of disease or unusual clusters of illness. South Dakota No S.D. ADMIN. R. 44:20:01:03 44:20:01:04 SD DH Tennessee No TENN. COMP. R. & REGS TN DH Texas Yes TEX. HEALTH & SAFETY CODE ; TX DSHS In addition to the statute requiring of drug overdoses (see Table 2 below), Texas s rule also provides: In addition to Page 5 Updated July 1, 2017

6 Jurisdiction Overdose required? Relevant Law or regulation Subregulatory source Notes 4 25 TEX. ADMIN. CODE 97.3 individual case reports, any outbreak, exotic disease, or unusual group expression of disease that may be of public health concern should be reported by the most expeditious means. Utah No UTAH ADMIN. CODE r UT DH In addition to the conditions listed in the rule, outbreaks, epidemics, or unusual occurrences of events [are] reportable by all entities. Vermont No 12 VT. CODE R. 5-12:5.0 VT DH Per the rule, any unexpected pattern of cases, suspected cases, deaths or increased incidence of any other illness of major public health concern, because of the severity of illness or potential for epidemic spread, which may indicate a newly recognized infectious agent, an outbreak, epidemic, related public health hazard [ ], must be reported. Virginia No 12 VA. ADMIN. CODE VA DH The occurrence of outbreaks or clusters of any illness which may represent a group expression of an illness which may be of public health concern shall be reported Washington No WASH. ADMIN. CODE WA DOH Jefferson and Clallam counties require ODs to be reported. See Table 2 below. West Virginia Yes W. VA. CODE R to WV DHHR Legislation passed in 2017 requires health care practitioners to report a patient s information to the state PDMP whenever that patient is treated for an overdose or a suspected overdose. See Table 2 below. Wisconsin No 5 WIS. STAT WI DHS The disease statute only requires of communicable disease. However, a separate law requires law enforcement to report fatal and non-fatal overdose to the state PDMP. See Table 2 below. Wyoming No WYO. CODE R. HLTH PHSD, Ch. 1, 1 WY DH National No Nationally Notifiable Diseases Surveillance System Event Code List Page 6 Updated July 1, 2017

7 Table 2: Jurisdictions with relevant legislation Jurisdiction Covered individuals or entities Information to be reported Department receiving information Reporting timeframe Arizona 6 Florida 8 Nevada New Mexico Healthcare providers, administrators of health care institutions and correctional facilities, EMS services, medical examiners, pharmacists, state and local law enforcement agencies, numerous departments and boards. Suspected opioid overdoses, suspected opioid deaths, naloxone doses administered and dispensed, neonatal abstinence syndrome. Arizona Department of Health Services A basic life support service or The date and time of overdose; the Florida Department of advanced life support service which approximate address of where the Health treats and releases, or transports to person was picked up or where the a medical facility, in response to an overdose took place; whether an emergency call for a suspected or actual overdose of a controlled substance may report 9 emergency opioid antagonist was administered; whether the overdose was fatal or nonfatal If possible: the gender and approximate age of the patient; the suspected controlled substance involved 1) Provider of health care who Board of Pharmacy to specify in knows of, or provides services to, a regulations person who...has suffered or is suspected of suffering a drug overdose (If no provider is providing services, each person having knowledge that another person has suffered or is suspected of suffering a drug overdose) 2) Medical facility in which more than one provider of health care may know or, or provide services to, a person who has suffered or is suspected of suffering a drug overdose Every health care professional treating any person or animal having or suspected of having any notifiable condition 10 Local health authorities. Health authorities must then report overdose cases to the state s Chief Medical Officer Disease or condition, patient s name, Epidemiology and date of birth/age, gender, race/ethnicity, Response Division, address, telephone number, occupation New Mexico Department of Health Health care professional s name, telephone number; health care facility and telephone number if applicable Within 24 hours 7 best efforts to report within 120 hours Board of Pharmacy to specify time frame in regulations Not specified Rhode Island 11 A health care professional who attends or treats, or who is requested to attend or treat, an opioid-related drug overdose or the administrator, or other person in charge of a hospital in which an opioid-related drug overdose is attended or treated Demographic information concerning the person attended or treated or for whom treatment was sought Health care professional may not disclose the person s name or address or any other information concerning the person s identity RI Department of Health Within 48 hours Page 7 Updated July 1, 2017

8 Jurisdiction Covered individuals or entities Information to be reported Department receiving information Reporting timeframe Office of the State Medical Examiner (OSME) 12 Cause, manner and circumstances of each OSME-confirmed accidental drug overdose death Office of Vital Records, RI Department of Health Not listed Texas 13 Physician who attends or treats, or who is requested to attend or treat, an overdose of a controlled substance listed in Penalty Group 1 under [state law] Person in charge of institution in which an overdose of a controlled substance is attended or treated Date of the overdose; type of controlled substance used; sex and age of the person; symptoms associated with overdose; extent of treatment made necessary by overdose; patient outcome. Physician may provide other demographic information but may not disclose patient s name or address or information concerning the person s identity Local poison center 14 at once Wisconsin 15 Law enforcement officer who [e]ncounters an individual who the law enforcement officer believes is undergoing or has immediately prior experienced an opioid-related drug 1) Name and date of birth of the individual who experienced an opioidrelated drug overdose or who died as a result of using a narcotic drug overdose or a deceased individual 2) The name of the prescribing who the law enforcement officer practitioner, the prescription number, believes died as a result of using a and the name of the drug as it appears narcotic drug on the prescription order or prescription medicine container if a prescription medicine container was in the vicinity of the suspected drug overdose or death [T]he law enforcement agency that employs him or her, which reports the information to the state PDMP Not specified; agency can postpone if would interfere with an active criminal investigation West Virginia 16 Medical services provider who The full legal name, address and birth Board of Pharmacy treats a patient for an overdose date of the person who is being treated, (PDMP) 17 that has occurred as a result of illicit including any known ancillary evidence or prescribed medication of the overdose Not specified 18 Clallam County, WA Selected healthcare providers and the county coroner Jefferson County, Hospital emergency departments WA and the county coroner 19 Patient information, drugs used at time of overdose, drug use history, location of overdose, information on any naloxone administered, outcome Both fatal and non-fatal overdoses of opioid-containing drugs. The person is to be identified. Clallam County Department of Health and Human Services Jefferson County Public Health Within 24 hours Not listed Page 8 Updated July 1, 2017

9 Table 3: Jurisdictions with proposed relevant legislation Jurisdiction Reporting Entity Is mandatory? Information Required Department receiving the information Reporting Timeframe Maryland A physician, pharmacist, dentist, or nurse who treats an individual for suspected overdose caused by a substance in Schedule I of state law or the individual in charge of a hospital that treats such a person Yes, failure to report is a misdemeanor publishable by a fine not exceeding $25 Name and address of the individual suspected to have overdosed; description of the type of overdose; any other facts that might assist in addressing overdose rates in the county in which the overdose occurred County sheriff or county police for the county in which the overdose occurred, or department of state police Within 48 hours of treatment New York 1) a hospital that has been issued an operating certificate by the commissioner [of health] Yes the name and such other data as may be required by the commissioner and the outcome of such treatment Commissioner of Health (Department of Health) promptly 2) every attending practitioner and every consulting practitioner with respect to any person treated for an opioid overdose SUPPORTERS The Network for Public Health Law is a national initiative of the Robert Wood Johnson Foundation. This document was developed by Corey Davis, J.D., M.S.P.H., Deputy Director, and Hector Hernandez-Delgado, Staff Attorney, Network for Public Health Law Southeastern Region. For further information, please contact Mr. Davis at cdavis@networkforphl.org. The Network for Public Health Law provides information and technical assistance on issues related to public health. The legal information and assistance provided in this document does not constitute legal advice or legal representation. For legal advice, please consult specific legal counsel. Page 9 Updated July 1, 2017

10 Notes 1 Centers for Disease Control and Prevention, New data show continuing opioid epidemic in the United States. December Available at 2 Green TC, Gilbert M. Counterfeit Medications and Fentanyl. JAMA Intern Med 2016;176: As noted in Table 1, many states have catch-all provisions under which overdose may currently be reportable, but it is not known whether and to what extent they are being utilized for that purpose. 4 Where state law, regulation, or sub-regulatory guidance contains language that could potentially be interpreted to encompass overdose, that language is provided in this column. 5 However, WI requires law enforcement to report overdoses to the state prescription drug monitoring program. See Table 2. 6 Executive Order , available at 7 See Arizona Department of Health Services, Frequently Asked Questions: Reporting, available at 8 HB 249 (2017). This law, which is not yet codified, goes into effect on October 1, Fla. Stat Drug overdose is a notifiable condition under state law. N.M. Code R See Rhode Island Department of Health, Rules and Regulations Pertaining to Opioid Overdose Reporting [R3-1-OP OID-R], available at 12 See Rhode Island Department of Health, Policy: Identifying and Reporting Confirmed Accidental Drug-Related Overdose Deaths, available at 13 TEX. HEALTH & SAFETY CODE Relevant statute requires that controlled substance overdoses be reported to the Department of State Health Services. However, the Department s list of Notifiable Diseases dictates that they instead be reported to the local poison center at WIS. STAT The West Virginia requirement will be codified at W. Va. Code 60A-9-4(b). It will be effective 90 days from April 8, The Board of Pharmacy shall coordinate with the Division of Justice and Community Services and the Office of Drug Control Policy regarding the collection of overdose data. W. Va. Code 60A-9-4(b). 18 The amendment requiring overdoses to be reported does not contain a timeframe, but regulations governing the PDMP generally specify that The information required to be submitted by the provisions of this rule.shall be transmitted at least within twenty-four (24) hours of the dispensing.. It is not clear if this provision applies to the overdose requirement, which is contained in statute and not rule. W. Va. Code R (4.1). 19 See Letter from Tom Locke, MD, MPH, Feb. 4, 2016, available at Page 10 Updated July 1, 2017